Ординатура / Офтальмология / Английские материалы / Orbital Tumors Diagnosis and Treatment_Karcioglu_2005

Exenteration

Exenteration, the surgical removal of the entire orbital contents, including the globe, optic nerve, extraocular muscles, lacrimal gland, and lacrimal drainage system, as well as the orbital fibroconnective and adipose tissues, is undertaken only in extreme circumstances, such as malignant invasive tumors or adenoid cystic carcinoma. Ninety percent of orbital exenterations are performed as a last resort for invasive neoplasma. Lesser indications for exenteration are for the irradiation of potentially life-threatening infections that cannot be controlled by other means and for the management of intractable pain or structural deformity, congenital or acquired. The last two groups comprise approximately 10% of all indications.80–82 This is radical, last-resort surgery, which is done infrequently even in large ophthalmic institutes.83,84

Exenteration may be performed either in total or subtotal fashion. Even when it is limited, exenteration is extensive, radical surgery, which needs to be explained in great detail to the patient and the family. There are two issues that need to be conveyed clearly. One is that the exenteration is usually the last resort of management and represents the failure of other treatments. Therefore, in many instances it may

or may not arrest the pathological process involved. That is, if the procedure is being attempted to control an invasive or recurrent adenoid cystic carcinoma, the tumor may recur despite this radical surgery, even though the surgery goes well. This needs to be understood by the patient and the family. It would also be wise to detail what the surgical procedure entails, what the postoperative care would include, and how such radical surgery would affect the patient’s appearance afterward. Depending on the patient’s willingness to understand, postoperative pictures from other cases may be shown to clear any misunderstanding about the extent of the surgery.

Whether the exenteration is performed in total or subtotal fashion, the objective of the operation is the same: to excise the pathologic tissues with clear margins. Therefore, the planning of surgery depends on the extent of the pathology, which may or may not include the eyelids, posterior orbit, or the bony wall. For example, if the exenteration is being performed for a squamous cell carcinoma of the conjunctiva that had extended into the globe and the eyelids, there may be no need to remove the posterior orbital soft tissues, which are usually not involved with tumor. Sparing them would facilitate the healing and reconstruction process (Figure 31.20). On the other hand, if the main

pathology is located posteriorly, such as a choroidal melanoma, extending into the orbit secondarily, there is no reason to remove the eyelids, and the procedure can be done as a lid-sparing exenteration. Individualization of exenteration cases should take into account the location, size, and aggressiveness of the pathology as well as the reconstruction plan. A recent report of 25 exenterations revealed that subtotal procedures would offer improved functional and aesthetic results, while being comparable to total exenteration procedures in terms of eradication of the disease.85

If the bones of the orbit are involved with malignancy, bone resection should be performed at the time of initial orbitotomy, even if that procedure is not an exenteration.20 In recurrent or advanced cases, the extent of the bone invasion should be mapped carefully with preoperative CT scans. At the time of exenteration, the bone should be removed well beyond the margins of the tumor depicted by CT, provided the part of the orbital wall is made of expendable bone. Wider margins are advisable in bone resection because frozen section monitoring cannot be done in bony tissue. Most of the orbital bone, except for the roof of the orbit and the orbital apex, can be removed after the exenteration. There are no standard techniques for

bone resection; in most cases, the removal depends on the extent and the location of the bony invasion. In most areas of the orbit, it is preferable to deeply incise the bone with an oscillating saw along the predetermined limits of resection and then attempt to break the bone en bloc with a strong rongeur. In some areas, this may not be difficult; in other sites, a sharp osteotome and a mallet may be needed to remove pathologic bone in layers (see Chapter 16; Figure 16.8).

Wide excision of the bone from the lateral wall of the orbit is usually indicated in cases of malignant epithelial tumors of the lacrimal gland. Long-term survival has been reported following this type of surgery.86,87 The removed pieces of bone should be properly oriented and labeled for permanent histopathologic examination to determine the extent of tumor. This may be a tedious procedure; however, it is a rewarding one to help decide whether the patient needs further treatment.

In total exenteration, the eyelids are secured in closed position with two silk sutures and a circumferential skin incision overlying the orbital rim is done (Figure 31.21). When the underlying soft tissues have been reached, the incision is continued with the use of unipolar cautery with a fine needle tip (Colorado

tip). From the standpoint of minimizing the bleeding, we prefer to begin the incision in the upper quadrant, around 12 o’clock, and proceed clockwise, postponing the dissection of the vascular nasal quadrant to the end of the procedure. Then the periorbita is elevated with a sharp-tipped periosteal elevator and further dissected with malleable retractors. When the periosteum of the orbital rim is reached, the periosteum is elevated and the dissection is swiftly continued beyond the rim into the orbit, to complete the procedure as quickly as possible. During dissection, which is done while the blood is suctioned, bleeding is ignored unless hemorrhage is so profuse that it interferes with the view of the surgical field. When the soft tissue dissection is complete, hemostasis with cautery and other means is addressed. Once the dissection toward the apex is completed 360°, one reaches posteriorly to the apical bundle of soft tissues, including extraocular muscles, blood vessels, and nerves. These abundant tissues at the tip of the orbital cone cannot be clamped or cut with one move. We approach this bundle from its nasal aspect, place a strong, curved hemostat, and cut the pedicle with unipolar cautery above the hemostat; then the same maneuver is repeated laterally and inferiorly to free the apex from orbital soft tissues. To cut the apical tissues with unipolar cautery reduces the hemorrhage somewhat, but the bleeding sources in the apex should be identified and clamped and tied after the removal of the bulk of the soft tissue. Application of electrocautery at the apex too much and too long may create damage in the remaining portion of the optic nerve, which may extend into the chiasm.

Alternatively, others approach the procedure with tedious attention to hemostasis throughout the dissection. The author’s preference, however, is the first approach, which shortens the procedure time; with today’s suction and cautery equipment, the total soft tissue excision can be done in less than 15 minutes without any significant blood loss. Most of the bleeding originates from the supraorbital and infraorbital bundles, the anterior and posterior ethmoidal arteries, and the ophthalmic artery, as the dissection reaches the apex. Although the posterior bleeding is the most significant, it is easier to control, since by the time one reaches the apex of the orbit, all soft tissues have been freed and the surgeon maintains better visibility. After the major bleeding sites are controlled by tying the vessels or cauterization, smaller bleeding sites are addressed by cautery, bone wax, or simply by pressing thrombin-soaked Gelfoam onto the sites of oozing; Avitene® may also be used to control bleeding.

Cerebrospinal fluid (CSF) leak is not a very common complication of orbital surgery in general.88 However, when leakage takes place during surgery or postoperatively, the procedure and/or hospitalization are prolonged and prognsosis may worsen. Since or-

bital exenteration is an extensive procedure, one expects CSF leak to occur more often. In a series of 39 exenteration cases reported by Bonovolonta and deConcilis, CSF leak was experienced approximately 18% of the time, and majority of patients had invasive secondary tumors from conjunctiva, eyelids, and globe.89 In 26 out of 39 cases, one or more orbital wall was removed, and, therefore, the dural exposure and the CSF leak incidence were higher.

When CSF leak takes place during surgery, the conventional treatment is to suture the dura whenever possible; when this is out of the question, the area is packed with temporalis muscle, fascia, or fibroadipose tissue. The successful use of cyanoacrylate adhesive for CSF leaks during orbital surgery has been reported.90 At times, particularly in CSF leaks that happen after surgery or ones that do not respond to repair and continue to leak intraoperatively, lumbar puncture to lower the CSF pressure may help.

In eyelid-sparing exenteration, one may need to spare either the entire eyelid structure or just the eyelid skin. If the eyelid skin is to be spared, the skin incision is placed approximately 2 to 3 mm above and below the lash lines in upper and lower eyelid, respectively. Then the skin is dissected superiorly and inferiorly until the orbital rim is reached; the periosteum outside 2 mm of the orbital rim is cut 360° to carry on the rest of the exenteration procedure. If the entire eyelid anatomy will be preserved, the operation is similar to an extended enucleation in which the eye with the bulbar conjunctival lining and the rest of the orbital tissues are removed en bloc. Eyelid-sparing subtotal exenteration offers significant advantages in terms of reconstruction of the orbit and cosmesis. The simplest approach to cosmetic rehabilitation is to pack the orbit with iodine gauze and let the socket granulate by itself.

When the eyelids are entirely removed, the free skin margin is tacked to the orbital rim with interrupted silk sutures for 360° and the socket is lined with antibiotic-soaked Vaseline or Xeroform gauze. Then more gauze is packed into the orbit, compressing the initial gauze strip lining firmly over the concavity of the orbital bones. Maxitrol ointment is then instilled to the edges of the wound, the exenteration cavity is covered with dry gauze squares, and a firm dressing is applied. In some instances, the interrupted 5-0 silk sutures at the skin margin may be left long and tied over the socket gauze pack (Figure 31.22). The initial dressing is removed 7 days postoperatively, and from then on the site should be irrigated frequently with 2% hydrogen peroxide solution. The initial debridement of the socket can be done at the clinic every other day or on third-day visits. After 2 weeks, the irrigation can be done with running water from a showerhead by the patient at home. The entire granulation process may take 8 to 10 weeks to complete (Figure

31.22). By the time the granulation is complete, the orbit is covered with a very thin layer, which has the advantage of allowing the detection of recurrent tumor at an early stage. The resulting cavity is deep but can usually be fitted well with a silicone oculofacial prosthesis (Figure 31.23). The cosmetic results of the prosthesis are acceptable, particularly with shaded glasses (Figure 31.24).

Alternatively, the socket may be lined immediately at the completion of the exenteration procedure with split-thickness skin graft. The recommended thickness for the graft varies, but it should be free of hair follicles. A graft measuring approximately 10 cm 5 cm in greatest dimensions would be sufficient to cover the orbital cavity. A graft of this size can easily be obtained from the front surface of the thigh. When the skin graft has been fitted into the orbit, one should ensure close approximation, preferably contact, of the graft to the recipient bony orbit. It is positioned and sutured to the marginal edges of the skin with interrupted absorbable sutures, and the orbit is packed with Xeroform gauze as a mold to provide firm apposition of the graft to the recipient area. Maxitrol ointment is applied to the edges of the skin, and a firm dressing is applied to keep the packing gauze in posi-

tion for 10 days.91 Some surgeons perforate the graft with small slits, which may make the fitting of the graft easier and allow an evacuation route for early postoperative bleeding, avoiding the accumulation of blood under the graft. Blood under the graft delays healing and may become a site of infection.

Although the orbits that are covered by skin grafts heal a few weeks faster than the uncovered ones, the grafted cavities have the disadvantage of not developing fibrosis to reduce the depth of the orbital cavity, which is commonly observed in the sockets that granulate on their own. Most surgeons agree that the orbits heal in a more uniform fashion without the skin graft; but the rehabilitation of the socket with numerous hospital visits for uncomfortable debridement and redressing of the socket makes this option rather unappealing for many patients.

To facilitate the healing of the exenteration socket, we use vacuum-assisted closure (VAC) in selected cases (Figure 31.25). The premise of this method is to apply controlled subatmospheric pressures to the wound to remove the edema, increase the localized blood flood, and enhance the formation of granulation tissue.90,92,93 The VAC technique entails placing an open-cell foam dressing into the exenteration cavity

at the end of surgery and sealing the socket with an adhesive plastic drape so that intermittent subatmospheric pressures can be applied to the socket during the next 2 to 3 days. The sterile foam dressing should be trimmed to fit into the socket and to allow the evacuation tube to sit centrally from the orbit (Figure 31.25). Cyclic intermittent negative pressures of 75 to 100 mmHg are used for 3 days while the patient is

still in the hospital. Although the patient remains attached to the VAC pump during the hospitalization, the negative pressure does not seem to cause discomfort, and the procedure is well tolerated. The granulation of the orbit is markedly expedited and the socket heals well within 4 to 5 weeks as opposed to the usual 8 to 10 weeks of the granulation process. The removal of the sponge from the socket may create some dis-

comfort, particularly in eyelid-preserved exenterations. It is advisable for the patient to be sedated when the sponge is removed at the bedside. Skillman and coworkers reported the utilization of the VAC for improved healing of split-thickness skin grafting in exenteration cavities.94,95

In certain cases in which the orbital tumor is extensive, an orbitocraniofacial approach may facilitate the exenteration.96,97

No matter what approach is used and how limited exenteration may be, it is still extensive surgery and requires considerable reconstruction work. The primary objectives of reconstruction are to reach an optimal aesthetic result by restoring the boundaries between the orbit and surrounding cavities while allowing enough visibility for follow-up examinations to detect recurrent disease. In many cases, allografts cannot be used extensively because of concern about recurrent tumor, and most surgeons prefer to let the exenterated orbit heal by secondary intention.91 Although this approach is not aesthetically ideal, the socket heals with a very thin layer of tissue, which allows early detection of recurrent tumor.

Regional surgical solutions, including transfer of the temporalis muscle and fascia and other regional

pedicle flaps, as well as myocutaneous flaps with microvascular anastomosis, offer better cosmetic results. However, these procedures should not be performed unless one is absolutely sure that the malignant process has been totally cured. In some instances, early placed flaps and free grafts cover the recurrent disease and delay its diagnosis. When it is confirmed that there is no recurrent malignancy at the site of surgery, regional flaps or vascular myocutaneous flaps may be used for cosmetic rehabilitation. A common procedure is to borrow a portion of the temporalis muscle from its anterior half, pass it through the lateral wall, and fill the orbital cavity with the bulk of this graft. Skin graft can later be positioned over the muscle flap; in most instances this procedure effectively makes the exenteration cavity shallow.98 Many patients are satisfied simply by wearing a black “pirate’s patch” over the defect; others prefer the use of oculofacial prostheses. Early reconstruction during the exenteration procedure with myocutaneous and other flaps may be considered in children, since the tissue transfer will allow much easier postoperative wound care than split-thickness skin grafting and primary intention healing. Primary reconstruction may be recommended for very old patients as well as young children who re-

quire orbital exenteration but cannot tolerate the traditional postoperative debridement process.99

WOUND CLOSURE AND

POSTOPERATIVE CARE

Wound closure is the last step of any surgical procedure. Although the techniques vary from one surgeon to another, certain basic principles should be followed. When the surgeon is ready to close the wound, layers of the exploration should be inspected, to ensure that the deep and superficial tissues are in optimal condition to be closed. All tissues, including bone, periosteum, orbital soft tissues, and skin/conjunctiva, should be properly approximated to their original anatomic planes as much as possible to minimize the functional deficit and postoperative scarring.

The bone is usually closed with heavy nylon or Prolene sutures; wires and bone fixation systems with metal plates and screws should be avoided. Although bioabsorbable bone fixation systems can be used, these devices are hardly necessary to reattach bone after tumor surgery. Alternatively, the bone may be repositioned in its original site without suturing and the periosteum may be pulled over to secure the underlying bone. For this purpose, the periosteum should be undermined. Another helpful point is to mark the edges of the periosteum with silk sutures at the time of incision; when the time of closure is reached, the periosteal layers are then easy to identify and reattach. The closure of the periosteum is usually accomplished with interrupted 5-0 or 6-0 Vicryl sutures.

The deep soft tissues of the orbit can be aligned and closed with 5-0 or 6-0 Vicryl sutures on a reverse cutting or spatula needle. It is best to close the subcutaneous tissues with an inverted suturing technique so that the knot will be hidden at the base of the closure, rather than being positioned immediately under the skin. Proper placement of deep sutures not only orients the tissues to their anatomic layers to minimize postoperative scarring but also avoids the “dead space” in between tissue recesses. “Dead space” between tissue planes leads to inaccurate wound closure and delays the wound healing; it also creates room for postoperative blood accumulation, which, in turn, may lead to infection. Then the overlying subcutaneous tissue and skin are closed with silk, nylon, or fast-absorbing gut sutures. In most tumor surgery cases, the margins of the skin are straight and clean as opposed to the ragged skin edges of trauma and infectious cases. Skin edges should be accurately positioned and sutured at two or three cardinal positions to ensure correct approximation. Then, interrupted sutures are placed between the initial cardinal sutures and tied with gentle eversion of the wound edges.

McCord and coworkers emphasize the proper eversion of the skin edges in closure to minimize postoperative functional deficit and scar formation.41,44 Larger skin wounds may be closed with horizontal mattress and “near-far/far-near” suturing techniques in which more uniform tension is applied to the wound. Although these techniques minimize postoperative scarring, they are hardly ever necessary for orbitotomy incisions. Subcuticular running 6-0 nylon suture may also be used for skin closure. It is helpful to place the running suture on a bolster for easy removal in the clinic. For eyelid incisions, where the skin is thin, subcutaneous closure is not necessary, and the skin is directly closed with interrupted 7-0 nylon sutures.

The drain should be placed carefully to ensure the best surgical results. The author’s preference is to insert a vacuum drain through an ab externo site. A Hemovac® drain or a 21-gauge butterfly tubing with cut holes can be used (Figure 31.26). Drain function should be checked by applying gentle suction, and the tubing of the drain should be anchored to the skin to avoid accidental displacement during the postoperative period. For lateral and superior orbitotomies, it is preferable to position the drain immediately adjacent to the lateral edge of the eyebrow in which the scar can be hidden. Incorporating the drain into the initial skin incision may increase the postoperative scar formation, particularly in black patients. Suturing the eyelids together after (or during) orbital surgery is bad practice because of its pressure effect on the eye and also because it does not allow the eye to be observed during the immediate postoperative period.

At the end of the orbitotomy, a red top laboratory tube is attached to the drain to evacuate the initial blood and residual fluids from the surgical site; the tube is replaced with a new one before the patient is sent to the recovery area. The vacuum tube should ideally be positioned inferior to the surgical site, where it can be taped onto the skin in a

FIGURE 31.26. Hemovac® drain in place one day after lateral orbitotomy.

Postoperative Complications

The most dreaded postoperative complication in orbital surgery is hemorrhage, which can happen overnight or weeks after surgery but generally occurs in the 4 to 6 days following the procedure. Because the orbit is small and closed, any size hematoma may be of significance, depending on its location. Generous application of ice and elevation of the head of the bed during the first 24 to 48 hours of the postoperative period reduce the likelihood of orbital bleeding; however, postoperative hemorrhage may happen even in patients without risk factors such as hypertension or hypocoagulability. Physician’s orders should be clearly written to alert the nursing staff to recognize symptoms of postoperative hemorrhage, including loss of vision, pain, and rapidly increasing proptosis. Small postoperative hematomas that produce some proptosis and chemosis but no pain or afferent pupillary defect can be observed under conservative treatment and usually get better within days. If a large postoperative hematoma is suspected, the eye should be examined immediately by checking the visual acuity, intraocular pressure, and the pupillary light reflex. Imaging studies, preferably MRI, should be obtained immediately. Even if an obvious nerve compression is not identified in the MRI image, but the clinical symptoms warrant an acute increase in intraorbital pressure, the patient should be managed urgently.

An acute rise in the pressure of the orbit may cause compressive optic neuropathy as well as hypoperfusion to the optic nerve and retina.13 If the patient complains of visual loss in the presence of rapidly developing painful proptosis, one should check orbital pressure. One can assess increased orbital pressure by digital palpation, by observation of pulsating retinal vessels, and by increased intraocular pressure. If the orbit is tense while the patient is still carrying a drain, the position of the drain tubing should be manipulated while it is placed on suction. Because of the fibrous septae and the fibrin loculations during the orbital surgery, the hematomas, which may be localized, can be evacuated with position change of the drain. A great majority of patients are on steroids and antibiotics after orbital surgery; however, addition of Manitol and Acetazolamide should be considered to lower the pressure. Acute increase in orbital pressure is an emergency, and if the high pressure persists it should be relieved surgically. The simplest and the most effective way of relieving the orbital pressure is a lateral canthotomy. This can easily be done with the lyses of the inferior crus of the lateral canthal tendon. If the pressure is not relieved, the superior crus is cut in the same fashion. When the canthotomy is done, the lids may not cover the cornea; the cornea should be protected with ointment, collagen shield, bandage contact lens, or light patching.

Imaging may reveal the localization of the blood, which sometimes can be evacuated with a 20-gauge needle (Figure 31.27). Subperiosteal hematomas are the easiest ones to tap with a needle. This maneuver can also be done under CT guidance. B-scan ultrasonography may also be useful to guide a needle into anteriorly located hematomas.

If all these maneuvers fail, and the increased orbital pressure cannot be relieved, the patient should be taken back to the operating room so that the wound can be opened to evacuate the blood. If bleeders are observed, hemostasis should be accomplished and new drains should be placed before reclosure.

The best protection against postoperative increase of intraorbital pressure, due to hematoma or infection, is the meticulous performance of orbital surgery. The chances of postoperative hemorrhage can be decreased with complete hemostasis before closing the orbital cavity and with proper placement of a drain. The patient should be extubated carefully without developing Valsalva maneuvers, and the blood pressure should slowly rise in cases of hypotensive anesthesia. Tight pressure dressings should be avoided; ice should immediately be applied to the orbit. A certain degree of hemorrhagic chemosis cannot be avoided after orbit surgery; this can be managed with ophthalmic oint-

FIGURE 31.27. Evacuation of blood (red arrows on MRI) from orbit with a 21-gauge catheter.

ments. On occasion, the chemosis in the inferior fornix becomes semisolid and persistent. In these cases, a roll of gauze soaked in Vaseline can be placed into the inferior fornix with pressure patching on the eye. This can be left in place for 24 hours.

Excessive traction or blind dissection of the orbital tissues may damage the nerves, causing postoperative sensory and motor complications. For example, abduction weakness after lateral orbitotomy is a common occurrence, but this usually subsides without any interference. One hundred fifty-two patients who underwent surgery for orbital tumors during a 7-year period were reviewed for surgical complications. The highest number of complications was recorded in lateral orbitotomies (35%).102 Ninety-seven anterior orbitotomies revealed minor problems in only 3% of the surgeries.

The complications of lateral orbitotomies included extraocular motility problems, particularly abduction deficit (17.5%) and loss of pupillary reflex (10%). Occasional cases of ptosis, neurotrophic keratitis, and intraorbital hemorrhage were also seen. The most significant risk factor was found to be the intraconal location of the tumor. The majority of the complications were associated with the lateral approach to excise intraconal tumors; tumor type did not appear to be a factor. Ptosis may also be a problem following lateral and superior orbitotomies. During these procedures it is common to have hemorrhages into the levator muscle with subsequent ptosis. Again, this is not usually persistent; it usually resolves in weeks to months. Damage to the superior division of the third nerve and injury in the orbital apex can also produce long-term ptosis.103 If ptosis is secondary to nerve laceration, the repair may take a long time; these patients should be observed for up to a year. Overzealous dissection may injure the ciliary ganglion in lateral orbitotomies, particularly after removal of intraconal lesions, and the patient may develop dilated, nonreactive pupil, postoperatively. Again, it may take up to 6 months for the repair process. In superior medial orbitotomies, if the trochlea is injured, the patient may develop acquired Brown’s syndrome, postoperatively. This usually resolves during observation. In superior lateral orbitotomies, the lacrimal gland or its connecting ductules may be damaged, resulting in dry eye in many patients. This is usually a permanent problem and should be managed with artificial tears, ointments, and punctal plugs.

Postoperative emphysema may occur in small amounts and in localized fashion following the orbitotomy, owing to established passages from the sinuses and nasal cavity to the orbit. Small localized pockets of air are benign and usually resolve within days. On the other hand, if the volume of air entrapped in the orbit is large enough to increase intraorbital pressure and compromise the optic nerve, evacuation

should be performed, preferably with a 20-gauge needle under ultrasonographic control.

Wound infection and dehiscence as well as orbital cellulitis are unusual postoperative complications following tumor surgery. However, if the patient develops signs and symptoms of an infection, broadspectrum antibiotics are given and cultures obtained from the wound or from the drainage fluid. Warm compresses should be applied. Imaging procedures, preferably MRI, should be done to identify localized abscess formation. If the patient fails to respond to medical treatment, the abscess should be evacuated in the operating room.

Another long-term complication in any surgical procedure is scar formation, which in general can be minimized with strict attention to precise surgical technique. The surgical approach for tumor patients is usually well planned and accomplished with relatively small skin incisions. Therefore, scars are seen less often after orbital tumor surgery than following treatment for other orbital problems, such as trauma and inflammation. On the other hand, conjunctival scarring and focal symblepharon formation can be seen after surgery and postoperative radiation. In certain cases, particularly in darkly pigmented individuals, there may be scarring of the periorbital skin at the incision site or at the site of the drain insertion. Contraction of the scar is the last phase of wound healing and may take a long time, extending over many weeks to months.104 Therefore, even if medical or surgical treatment is contemplated to revise a scar, this should not be undertaken until the area has stabilized, usually after several months. Some of the hypertrophic scars and keloids may respond to steroid ointments or intradermal injection of steroids or low-dose radiation. For example, 0.1 mL of triamcinolone (Kenalog) may be directly injected into the scar with a 27or 30-gauge needle; the injections may be repeated every 2 weeks. Darkly pigmented individuals may experience depigmentation. A certain degree of response is obtained in hypertrophic scars, but keloids usually recur.105 If there is severe contracture and irregularity of the skin, excision of the scar (scar revision) and/or skin grafting may be indicated; scar revision surgery is rarely needed after planned orbitotomies. More significantly, scarring may take place within the underlying soft tissues of the wound owing to excessive dissection, cauterization, hemorrhage, or improper closure of the soft tissues and periosteum. Scar formation around the extraocular muscles and peripheral nerves may result in the malfunction of the involved structures; most commonly leading to postoperative diplopia.103 In most cases, diplopia also resolves over the coming months; if it does not, in the absence of recurrent tumor, the possibility of strabismus surgery should be entertained.

Conjunctival scarring and symblepharon may also occur occasionally, but these scars are usually small